Programs: Maryland Medical Assistance Program (MA)

Max Days 180

Requests to override Days Supply are directed to Maryland Medicaid at (410) 767-1755.

Providers will have the ability to override Days Supply Limits and/or PA required conditions by entering a value of ‘5’ (exemption from prescription limits) in the Prior Auth Type Code field (NCPDP field # 416-DG). Note:

This override situation applies to TPL processing only

A value of 5 in the Prior Auth Type Code field is valid only if Other Coverage Code = 2 (other coverage exists-payment collected)

A value of 8 in the Prior Auth Type Code field is valid only if recipient is pregnant (this will override both coverage limitations and copay)

ACS will ensure the following rules for refills

· Non-Controlled Covered Drugs:

Max 11 refills

Max 360 days supply total with refills

Do not allow a refill on a prescription to be filled 360 days or more from the date prescribed.

· Controlled Covered Drugs- Schedules III, IV and V:

Max 5 refills

Max 180 days supply total with refills

Do not allow a refill on a prescription to be filled 180 days or more from the date prescribed.

Do not fill original prescription greater than 30 days from the day prescribed

· Controlled Covered Drugs- Schedule II

No refills allowed

Max 100 days supply on the original prescription

Do not fill original prescription greater than 30 days from the day prescribed
MANDATORY GENERIC REQUIREMENTS:

Maryland Medicaid has a mandatory generic substitution policy.

DAW 0 Default, no product selection

DAW 1 Physician request

DAW 5 Brand used as generic

DAW 6 Override

The system will deny brand drugs when a generic is available with edit 22 (M/I /DAW code) and the message text: “Generic Available – Call State at 410-767-1755, MedWatch form required” when submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC):

Levothyroxine HICL seq Num = 002849

Brimonidine eye drops GSN = 48333 and 27882

MAXIMUM DOLLAR AMOUNTS

The system will allow a max cost per prescription of $2500.00 including compounds.

The system will deny claims that exceed the maximum dollar limit of $2500.00 with error 78 (Cost Exceeds Max) and the message text “Contact ACS at 1-800-932-3918 to request override”.

The ACS Prior Authorization (PA) Call Center Pharmacist may approve prior authorization requests for dollar limit overrides after validating the quantity submitted.

Note: When reviewing submitted claims over $2,500.00, ACS PA Call Center Pharmacist will consider the following minimal criteria:

Proper dispensing units are being submitted, as per the ACS System editing criteria;

Proper days supply being submitted as per number of units dispensed;

Proper FDA dosing guidelines being followed; and

Quantity limitations that already exist as system edits.

The reviewer will use professional judgment and the above minimal criteria to preauthorize a claim. Claims not in compliance with profession judgment and minimal criteria will be denied.
Prior Authorization

There are four methods a provider can receive a Prior Authorization for Maryland (OOEP) Medicaid recipients:

ACS Technical Call Center

Maryland Medicaid Staff

CAMP office

SmartPA

PA denials handled by ACS will return the following message text in the response: “Prior Authorization Required, Call ACS at 1-800-932-3918 (24/7/365)”.

PA denials handled by the State will return the following message text in the response: ”Prior Authorization Required, Call MD/ OOEP at (410) 767-1755, M-F, 8:30 am – 4:30 pm”.

PA denials handled by the State's CAMP Office will return the following message text in the response: “Prior Authorization Required, call CAMP Office, (410) 706-3431”.

Below is a list of drugs that require Prior Authorization and which office handles the Prior Authorization request:
The Maryland Pharmacy Program staff:

Days Supply

Growth Hormones

Synagis (Palivizumab)

Female Hormones for a male and vice versa

Nutritional supplements (see MD PA form for clinical criteria)

Recipient Lock-In

Price (long-term PAs only)

Oxycontin Quantity (during business hours)

Antihemophilic Drugs (claim pended in X2 and evaluated manually by State)

Duragesic Patch Quantity (during business hours)

Topical Vitamin A Derivatives

Opiate Agonists for Hospice and Hospice/LTC

Antiemetic

Serostim

Botox

Revlimid

Brand Medically Necessary

Quantity (Note Oxycontin, Duragesic Patch exceptions)

CNS Stimulants

Actiq

Anti-Psychotics (quantity limits)

Oxycontin, Duragesic Patch Qty for after hours/weekends

Maximum dollar limit per claim = $2,500

Depo Provera

Lupron Depot
ACS Technical Call Center:

PDL - Non-Preferred drugs

Early Refill & Days Supply

Age Restrictions

Max Quantity overrides
SmartPA

SmartPA is an automated, rules engine, driven system that uses both the medical and pharmacy information to either grant a Prior Authorization or deny based on the rules for that particular drug being dispensed. If criteria are met upon claims submission, no call for PA will be required. The system will automatically generate a Prior Authorization and the claim will pay. When a claim is denied by SmartPA, the exception message will state which criteria was not met in order for the PA to be issued. Below is a list of drugs / categories that will be handled by SmartPA:

CNS Stimulants

Actiq

Atypical Antipsychotics

Serostim

Botox

Growth Hormones

Antiemetics

Topical Vitamin A

Orfadin

Revlamid

Nutritional Supplements

Oxycodone
MENTAL HEALTH DRUGS

ACS will process claims for the Mental Health Carve-out drugs. Claims submitted for non Mental Health Carve-out drugs using the Medicaid PCN and Group ID will deny with NCPDP reject code 65 (Patient Not Covered). These claims must be sent to the MCO for processing. Claims for Mental Health Carve-out drugs MUST be sent to the following:

BIN: 610084

Processor Control #: Maryland Medicaid DRMDPROD

Group #: Maryland Medicaid MDMEDICAID